BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For ayUST permanent closure or removal,complete only this section and Sections I,11,111,IV,and IX below) 430 ❑ 1.NEW PERMIT [0 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID M(Agency Use Only) 'D7, r 4� I BUSINESS VA77GG� m,ps SLI /4 NSE+�or � of iusine As /iyM OC:5 rOve4/ P�, AZ4 3 BUSINESS SITE ADDRESSn Coo �{I -jf A/J L /1 N 1Q0 CITY I A_.-�ff F V/)n IN II.TANK DESCRIPTION TANK ID M 432 TANK MANUFACTURER I r� 433 IT�ANK CONFIGURATION: THIS TANK IS 434�! STAND-ALONETANK f�� v L7� ONE M A COMPARTMENTED UMT. Com l.le we a for each mm.nmml in Ne wd1. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 3 437 lC III.TANK USE AND CONTENTS TANK USE EYIe.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ I..AVIATION FUELING 439 Cl 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used 0d) ❑ 5.EMERGENCY GENERATOR FUEL IHSC 615381.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER (Specify): 439. CONTENTS PETROLEUM: [IID Is.REGULAR UNLEADED ❑ le.MGRADE UNLEADED b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8,PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): "Ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ LSINGLEW'ALL Ein.PBUBLEWALL [1 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL UV.F BERGLASS ❑ 6.INTERNAL BLADDER '444 ❑ 7.STEEL+INTERNAL E ING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ff 95.UNKNOWN ❑99.OTHER(S eci 445. OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS U 2,BALL FLOAT IV 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUC /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1 INGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): Ora. SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 9 UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE WI.SINGLE WALL ❑ 2.DOUBLE WALL 090.NONE 4Md VI.VENT,VAPO ECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Jd I STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4We 4Wel VENT SECONDARY CONTAINMENT LZ I.STEEL ❑ 4. IBERGLASS [110.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify) 464f 4648 VR PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL lssl,%FIBERGLASS ❑ 10.RIGID PLASTIC 90.❑ 9 .NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLEWALL ❑ 2.DOUBLE WALL NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1 TEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 ONE ❑ 99.OTHER(Specify) 4641 64'I RISER SECONDARY CONTAINMENT VL,STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED NY 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451as I.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ .DOABLE WALL ❑ 3.NO DISPENSERS El 90.NONE 469, CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify)) 4691-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system E mpatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full cAnpliaihcewitlegal re uirements. 0 APPLICANT SIGNATURE DATE • '1) 4J0, .APPLICANT NAME(print) 471, APPLICANT TITL , 4vz. UPCF UST-B-112 r J ^ a+ Rev.(12/2007)